Integrative practices for anxiety

April 2015

By Kelsey Finke, BS and Julie McKee, MD

Defining psychological disorders can be very challenging since it involves the debate over what is normal versus abnormal. This task is further complicated by cultural differences for behavioral norms. Stress and anxiety are part of the natural order of human emotional experience and do not inherently constitute a disorder.1 Stress can be a healthy response to a dangerous situation and can be quite helpful in the short term. It is when stress and worry become longstanding and constant that there can be a significant decline in health and daily function. Recognizing the signs and symptoms of an anxiety disorder is very important because an estimated 25% of the general US population will at one time in their life experience an anxiety disorder.

Benzodiazepines have been a popular shortterm treatment for anxiety reduction.1 Selective serotonin reuptake inhibitors (SSRI’s) have now become the leading treatment for anxiety disorders. Although they were initially used for depression, SSRI’s have been proven effective for treating anxiety. They have the added benefit of treating comorbid depression as well. Conventional medical treatment for anxiety disorders places a large emphasis on drug treatment alone, often with no accompanying psychological or lifestyle counseling.

One of the most popular and effective therapeutic approaches for dealing with mental illness is cognitive behavior therapy (CBT). CBT works on the theory that our actions (behavior) are driven by our beliefs (cognitions). Exposure therapy is a useful CBT technique for the treatment of anxiety disorders, especially phobia disorders. Exposure therapy involves having the individual confront the feared object or scenario; this confrontation can be physical or through mental imagery. Therapists have different approach options for conducting exposure therapy. There is the gradual approach, which starts with a relatively innocuous anxious stimulus and builds to the worst stimulus. This restrained approach allows the individual to develop coping mechanisms that can be strengthened with each exposure. In contrast, the flooding method entails starting with the most fearful situation the individual can imagine. The benefit of flooding is a potential for a quicker desensitization because the individual is forced to face their absolute worst stimulus and recognize their world did not end. During the encounter, the therapist will guide the patient through reality testing to help reveal maladaptive thinking and behaviors. Reality testing challenges the accuracy of the individual’s thinking process and thought distortions. The hope is that by exposing flaws in the belief system the patient can develop healthier belief systems and decreased symptoms of anxiety.

Exercise is a helpful adjunct to the treatment of anxiety. Cardiovascular workouts such as brisk walking, jogging, aerobics and dance can be used to decrease symptoms of anxiety. Also, exercise modalities such as yoga and Pilates can be very helpful to relieve chronic stress and anxiety. The effect of nutrition on symptoms of anxiety has been another area of extensive research. When evaluating patients for anxiety, one should inquire about the use of caffeine and other stimulants. Energy drinks and large amounts of caffeine may be causing the symptoms of anxiety and simply discontinuing the offending substance may alleviate the problem. Also, it has been observed that people who eat diets rich in fish had lower rates of depression and inflammatory disorders. Both flax seed oil and fish oil contain anti-inflammatory omega-3 fatty acids. However, the types of omega-3 fatty acids in fish oil (EPA and DHA) have shown to be more effective than the ALA subtype in flax seed oil. In one study, medical students were given a pill containing fish oil or a placebo that contained a mixture of oils found in a typical American diet. The fish oil pill had an EPA/DHA ratio of 7:1 because EPA has a higher theoretical anti-depressant quality. Over a period of 12 weeks, the subjects had their blood drawn on non-stressful days and stressful days (the day prior to exams). Results showed students who received fish oil supplements had a “14% decrease in stimulated IL-6 production and a 20% reduction in anxiety symptoms compared to controls.” The study proved supplementation with fish oil may be helpful to reduce anxiety.2

A growing area of research is the effect of mindfulness meditation at a cellular and emotional level. Mindfulness practices encourage letting go of negative stress arousal and instead focus on the present. A common mindfulness practice that can be utilized with patients is breath-awareness. Patients focus on inhalation and exhalation while allowing thoughts to pass without judgment. In a recent study, individuals with GAD were assigned to either a mindfulness meditation practice group or a group that used standard stress management education. The mindfulness group practiced breath-awareness, body-scans and yoga. Participants in mindfulness meditation demonstrated significantly lower scores on anxiety screening test when compared with the standard stress management education group. The effect size for the mindfulness meditation group was similar to the effect size found in studies of CBT. 3

When treating anxiety, physicians should integrate psychological counseling, nutrition guidance, exercise recommendations and meditation practices into the treatment plan rather than to rely only pharmaceutical treatments.

Barlow, D., & Durand, V. (2009). Abnormal Behavior in Historical Context and Anxiety Disorders. In Abnormal Psychology: An Integrative Approach (5th ed., pp. 2-24, 121- 165). Belmont,CA: Wadsworth Cengage Learning.

Kiecolt-Glaser, J., Belury, M., Andridge, R., Malarkey, W., & Glaser, R. (2011). Omega-3 supplementation lowers inflammation and anxiety in medical students: A randomized controlled trial. Brain, Behavior and Immunity, 25(8), 1725-1734.

Hodge, E., Bui, E., Marques, L., Metcalf, C., Morris, L., Robinaugh, D., ... Simon, N. (2014). Randomized Controlled Trial of Mindfulness Meditation for Generalized Anxiety Disorder: Effects on Anxiety and Stress Reactivity. Journal Clinical Psychiatry